Healthcare Provider Details

I. General information

NPI: 1902364870
Provider Name (Legal Business Name): KAOMD JD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 AMHERST DR SE
ALBUQUERQUE NM
87106-1502
US

IV. Provider business mailing address

512 AMHERST DR SE
ALBUQUERQUE NM
87106-1502
US

V. Phone/Fax

Practice location:
  • Phone: 505-582-2478
  • Fax:
Mailing address:
  • Phone: 505-582-2478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: KURT OLSON
Title or Position: OWNER
Credential: MD
Phone: 505-264-4277